Paulsen, A. W. “Essentials of Anesthesia Delivery.

”
The Biomedical Engineering Handbook: Second Edition.
Ed. Joseph D. Bronzino
Boca Raton: CRC Press LLC, 2000
 84
Essentials of
Anesthesia Delivery

84.1 Gases Used During Anesthesia and their Sources

Oxygen • Air • Nitrous Oxide • Carbon Dioxide • Helium
84.2 Gas Blending and Vaporization System
84.3 Breathing Circuits
84.4 Gas Scavenging Systems
84.5 Monitoring the Function of the Anesthesia
Delivery System
84.6 Monitoring the Patient
Control of Patient Temperature • Monitoring the Depth of
Anesthesia • Anesthesia Computer-Aided Record Keeping •
A. William Paulsen Alarms • Ergonomics • Simulation in Anesthesia •
Emory University Reliability

The intent of this chapter is to provide an introduction to the practice of anesthesiology and to the
technology currently employed. Limitations on the length of this work and the enormous size of the
topic require that this chapter rely on other elements within this Handbook and other texts cited as
general references for many of the details that inquisitive minds desire and deserve.
The practice of anesthesia includes more than just providing relief from pain. In fact, pain relief can
be considered a secondary facet of the specialty. In actuality, the modern concept of the safe and efficacious
delivery of anesthesia requires consideration of three fundamental tenets, which are ordered here by
relative importance:
1. maintenance of vital organ function
2. relief of pain
3. maintenance of the “internal milieu”
The first, maintenance of vital organ function, is concerned with preventing damage to cells and organ
systems that could result from inadequate supply of oxygen and other nutrients. The delivery of blood
and cellular substrates is often referred to as perfusion of the cells or tissues. During the delivery of an
anesthetic, the patient’s “vital signs” are monitored in an attempt to prevent inadequate tissue perfusion.
However, the surgery itself, the patient’s existing pathophysiology, drugs given for the relief of pain, or
even the management of blood pressure may compromise tissue perfusion. Why is adequate perfusion
of tissues a higher priority than providing relief of pain for which anesthesia is named? A rather obvious
extreme example is that without cerebral perfusion, or perfusion of the spinal cord, delivery of an
anesthetic is not necessary. Damage to other organ systems may result in a range of complications from
delaying the patient’s recovery to diminishing their quality of life to premature death.

© 2000 by CRC Press LLC

 In other words, the primary purpose of anesthesia care is to maintain adequate delivery of required
substrates to each organ and cell, which will hopefully preserve cellular function. The second principle
of anesthesia is to relieve the pain caused by surgery. Chronic pain and suffering caused by many disease
states is now managed by a relatively new sub-specialty within anesthesia, called Pain Management.
The third principle of anesthesia is the maintenance of the internal environment of the body, for
example, the regulation of electrolytes (sodium, potassium, chloride, magnesium, calcium, etc.), acid-
base balance, and a host of supporting functions on which cellular function and organ system commu-
nications rest.
The person delivering anesthesia may be an Anesthesiologist (physician specializing in anesthesiology),
an Anesthesiology Physician Assistant (a person trained in a medical school at the masters level to
administer anesthesia as a member of the care team lead by an Anesthesiologist), or a nurse anesthetist
(a nurse with Intensive Care Unit experience that has additional training in anesthesia provided by
advanced practice nursing programs). There are three major categories of anesthesia provided to patients:
(1) general anesthesia; (2) conduction anesthesia; and (3) monitored anesthesia care. General anesthesia
typically includes the intravenous injection of anesthetic drugs that render the patient unconscious and
paralyze their skeletal muscles. Immediately following drug administration a plastic tube is inserted into
the trachea and the patient is connected to an electropneumatic system to maintain ventilation of the
lungs. A liquid anesthetic agent is vaporized and administered by inhalation, sometimes along with
nitrous oxide, to maintain anesthesia for the surgical procedure. Often, other intravenous agents are used
in conjunction with the inhalation agents to provide what is called a balanced anesthetic.
Conduction anesthesia refers to blocking the conduction of pain and possibly motor nerve impulses
traveling along specific nerves or the spinal cord. Common forms of conduction anesthesia include spinal
and epidural anesthesia, as well as specific nerve blocks, for example, axillary nerve blocks. In order to
achieve a successful conduction anesthetic, local anesthetic agents such as lidocaine, are injected into the
proximity of specific nerves to block the conduction of electrical impulses. In addition, sedation may be
provided intravenously to keep the patient comfortable while he/she is lying still for the surgery.
Monitored anesthesia care refers to monitoring the patient’s vital signs while administering sedatives
and analgesics to keep the patient comfortable, and treating complications related to the surgical proce-
dure. Typically, the surgeon administers topical or local anesthetics to alleviate the pain.
In order to provide the range of support required, from the paralyzed mechanically ventilated patient
to the patient receiving monitored anesthesia care, a versatile anesthesia delivery system must be available
to the anesthesia care team. Today’s anesthesia delivery system is composed of six major elements:
1. The primary and secondary sources of gases (O2, air, N2O, vacuum, gas scavenging, and possibly
CO2 and helium).
2. The gas blending and vaporization system.
3. The breathing circuit (including methods for manual and mechanical ventilation).
4. The excess gas scavenging system that minimizes potential pollution of the operating room by
anesthetic gases.
5. Instruments and equipment to monitor the function of the anesthesia delivery system.
6. Patient monitoring instrumentation and equipment.
The traditional anesthesia machine incorporated elements 1, 2, 3, and more recently 4. The evolution
to the anesthesia delivery system adds elements 5 and 6. In the text that follows, references to the “anesthesia
machine” refer to the basic gas delivery system and breathing circuit as contrasted with the “anesthesia
delivery system” which includes the basic “anesthesia machine” and all monitoring instrumentation.

84.1 Gases Used During Anesthesia and their Sources

Most inhaled anesthetic agents are liquids that are vaporized in a device within the anesthesia delivery
system. The vaporized agents are then blended with other breathing gases before flowing into the

© 2000 by CRC Press LLC

breathing circuit and being administered to the patient. The most commonly administered form of
anesthesia is called a balanced general anesthetic, and is a combination of inhalation agent plus intrave-
nous analgesic drugs. Intravenous drugs often require electromechanical devices to administer an appro-
priately controlled flow of drug to the patient.
Gases needed for the delivery of anesthesia are generally limited to oxygen (O2), air, nitrous oxide
(N2O), and possibly helium (He) and carbon dioxide (CO2). Vacuum and gas scavenging lines are also
required. There needs to be secondary sources of these gases in the event of primary failure or questionable
contamination. Typically, primary sources are those supplied from a hospital distribution system at
345 kPa (50 psig) through gas columns or wall outlets. The secondary sources of gas are cylinders hung
on yokes on the anesthesia delivery system.

Oxygen
Oxygen provides an essential metabolic substrate for all human cells, but it is not without dangerous
side effects. Prolonged exposure to high concentrations of oxygen may result in toxic effects within the
lungs that decrease diffusion of gas into and out of the blood, and the return to breathing air following
prolonged exposure to elevated O2 may result in a debilitating explosive blood vessel growth in infants.
Oxygen is usually supplied to the hospital in liquid form (boiling point of –183°C), stored in cryogenic
tanks, and supplied to the hospital piping system as a gas. The efficiency of liquid storage is obvious
since 1 liter of liquid becomes 860 liters of gas at standard temperature and pressure. The secondary
source of oxygen within an anesthesia delivery system is usually one or more E cylinders filled with
gaseous oxygen at a pressure of 15.2 MPa (2200 psig).

Air (78% N2, 21% O2, 0.9% Ar, 0.1% Other Gases)
The primary use of air during anesthesia is as a diluent to decrease the inspired oxygen concentration.
The typical primary source of medical air (there is an important distinction between “air” and “medical
air” related to the quality and the requirements for periodic testing) is a special compressor that avoids
hydrocarbon based lubricants for purposes of medical air purity. Dryers are employed to rid the com-
pressed air of water prior to distribution throughout the hospital. Medical facilities with limited need
for medical air may use banks of H cylinders of dry medical air. A secondary source of air may be available
on the anesthesia machine as an E cylinder containing dry gas at 15.2 MPa.

Nitrous Oxide
Nitrous oxide is a colorless, odorless, and non-irritating gas that does not support human life. Breathing
more than 85% N2O may be fatal. N2O is not an anesthetic (except under hyperbaric conditions), rather
it is an analgesic and an amnestic. There are many reasons for administering N2O during the course of
an anesthetic including: enhancing the speed of induction and emergence from anesthesia; decreasing
the concentration requirements of potent inhalation anesthetics (i.e., halothane, isoflurane, etc.); and as
an essential adjunct to narcotic analgesics. N2O is supplied to anesthetizing locations from banks of
H cylinders that are filled with 90% liquid at a pressure of 5.1 MPa (745 psig). Secondary supplies are
available on the anesthesia machine in the form of E cylinders, again containing 90% liquid. Continual
exposure to low levels of N2O in the workplace has been implicated in a number of medical problems
including spontaneous abortion, infertility, birth defects, cancer, liver and kidney disease, and others.
Although there is no conclusive evidence to support most of these implications, there is a recognized
need to scavenge all waste anesthetic gases and periodically sample N2O levels in the workplace to maintain
the lowest possible levels consistent with reasonable risk to the operating room personnel and cost to
the institution [Dorsch and Dorsch, 1998]. Another gas with analgesic properties similar to N2O is xenon,
but its use is experimental, and its cost is prohibitive at this time.

© 2000 by CRC Press LLC

 TABLE 84.1 Physical Properties of Gases Used During Anesthesia
Density Viscosity Specific Heat
GAS Molecular Wt. (g/L) (cp) (KJ/Kg°C)

Oxygen 31.999 1.326 0.0203 0.917

Nitrogen 28.013 1.161 0.0175 1.040
Air 28.975 1.200 0.0181 1.010
Nitrous oxide 44.013 1.836 0.0144 0.839
Carbon dioxide 44.01 1.835 0.0148 0.850
Helium 4.003 0.1657 0.0194 5.190

TABLE 84.2 Physical Properties of Currently Available Volatile Anesthetic Agents

Agent Boiling Point Vapor Pressure Liquid Density MAC*
Generic Name (°C at 760 mmHg) (mmHg at 20°C) (g/ml) (%)

Halothane 50.2 243 1.86 0.75

Enflurane 56.5 175 1.517 1.68
Isoflurane 48.5 238 1.496 1.15
Desflurane 23.5 664 1.45 6.0
Sevoflurane 58.5 160 1.51 2.0

* Minimum Alveolar Concentration is the percent of the agent required to provide

surgical anesthesia to 50% of the population in terms of a cummulative dose response
curve. The lower the MAC, the more potent the agent.

Carbon Dioxide
Carbon dioxide is colorless and odorless, but very irritating to breathe in higher concentrations. CO2 is
a byproduct of human cellular metabolism and is not a life-sustaining gas. CO2 influences many physi-
ologic processes either directly or through the action of hydrogen ions by the reaction CO2 + H2O ↔
H2CO3 ↔ H+ + HCO3–. Although not very common in the U.S. today, in the past CO2 was administered
during anesthesia to stimulate respiration that was depressed by anesthetic agents and to cause increased
blood flow in otherwise compromised vasculature during some surgical procedures. Like N2O, CO2 is
supplied as a liquid in H cylinders for distribution in pipeline systems or as a liquid in E cylinders that
are located on the anesthesia machine.

Helium
Helium is a colorless, odorless, and non-irritating gas that will not support life. The primary use of
helium in anesthesia is to enhance gas flow through small orifices as in asthma, airway trauma, or tracheal
stenosis. The viscosity of helium is not different from other anesthetic gases (refer to Table 84.1) and is
therefore of no benefit when airway flow is laminar. However, in the event that ventilation must be
performed through abnormally narrow orifices or tubes which create turbulent flow conditions, helium
is the preferred carrier gas. Resistance to turbulent flow is proportional to the density rather than viscosity
of the gas and helium is an order of magnitude less dense than other gases. A secondary advantage of
helium is that it has a large specific heat relative to other anesthetic gases and therefore can carry the
heat from laser surgery out of the airway more effectively than air, oxygen, or nitrous oxide.

84.2 Gas Blending and Vaporization System

The basic anesthesia machine utilizes primary low pressure gas sources of 345 kPa (50 psig) available
from wall or ceiling column outlets, and secondary high pressure gas sources located on the machine as
pictured schematically in Fig. 84.1. Tracing the path of oxygen in the machine demonstrates that oxygen
comes from either the low pressure source, or from the 15.2 Mpa (2200 psig) high pressure yokes via

© 2000 by CRC Press LLC

FIGURE 84.1 Schematic diagram of gas piping within a simple two-gas (oxygen and nitrous oxide) anesthesia
machine.

cylinder pressure regulators and then branches to service several other functions. First and foremost, the
second stage pressure regulator drops the O2 pressure to approximately 110 kPa (16 psig) before it enters
the needle valve and the rotameter type flowmeter. From the flowmeter O2 mixes with gases from other
flowmeters and passes through a calibrated agent vaporizer where specific inhalation anesthetic agents
are vaporized and added to the breathing gas mixture. Oxygen is also used to supply a reservoir canister
that sounds a reed alarm in the event that the oxygen pressure drops below 172 kPa (25 psig). When the
oxygen pressure drops to 172 kPa or lower, then the nitrous oxide pressure sensor shutoff valve closes
and N2O is prevented from entering its needle valve and flowmeter and is therefore eliminated from the
breathing gas mixture. In fact, all machines built in the U.S. have pressure sensor shutoff valves installed
in the lines to every flowmeter, except oxygen, to prevent the delivery of a hypoxic gas mixture in the
event of an oxygen pressure failure. Oxygen may also be delivered to the common gas outlet or machine
outlet via a momentary normally closed flush valve that typically provides a flow of 65 to 80 liters of O2
per minute directly into the breathing circuit. Newer machines are required to have a safety system for
limiting the minimum concentration of oxygen that can be delivered to the patient to 25%. The flow
paths for nitrous oxide and other gases are much simpler in the sense that after coming from the high
pressure regulator or the low pressure hospital source, gas is immediately presented to the pressure sensor
shutoff valve from where it travels to its specific needle valve and flowmeter to join the common gas line
and enter the breathing circuit.

© 2000 by CRC Press LLC

FIGURE 84.2 Schematic diagram of a calibrated in-line vaporizer that uses the flow-over technique for adding
anesthetic vapor to the breathing gas mixture.

Currently all anesthesia machines manufactured in the U.S. use only calibrated flow-through vapor-
izers, meaning that all of the gases from the various flowmeters are mixed in the manifold prior to
entering the vaporizer. Any given vaporizer has a calibrated control knob that, once set to the desired
concentration for a specific agent, will deliver that concentration to the patient. Some form of interlock
system must be provided such that only one vaporizer may be activated at any given time. Figure 84.2
schematically illustrates the operation of a purely mechanical vaporizer with temperature compensation.
This simple flow-over design permits a fraction of the total gas flow to pass into the vaporizing chamber
where it becomes saturated with vapor before being added back to the total gas flow. Mathematically
this is approximated by:

QVC ∗ PA
FA =
( )
PB ∗ QVC + QG − PA ∗ QG

where FA is the fractional concentration of agent at the outlet of the vaporizer, QG is the total flow of gas
entering the vaporizer, QVC is the amount of QG that is diverted into the vaporization chamber, PA is the
vapor pressure of the agent, and PB is the barometric pressure.
From Fig. 84.2, the temperature compensator would decrease QVC as temperature increased because
vapor pressure is proportional to temperature. The concentration accuracy over a range of clinically

© 2000 by CRC Press LLC

expected gas flows and temperatures is approximately ± 15%. Since vaporization is an endothermic
process, anesthetic vaporizers must have sufficient thermal mass and conductivity to permit the vapor-
ization process to proceed independent of the rate at which the agent is being used.

84.3 Breathing Circuits

The concept behind an effective breathing circuit is to provide an adequate volume of a controlled
concentration of gas to the patient during inspiration, and to carry the exhaled gases away from the
patient during exhalation. There are several forms of breathing circuits which can be classified into 2
basic types; (1) open circuit, meaning no rebreathing of any gases and no CO2 absorber present; and
(2) closed circuit, indicating presence of CO2 absorber and some rebreathing of other gases. Figure 84.3
illustrates the Lack modification of a Mapleson open circuit breathing system. There are no valves and
no CO2 absorber. There is a great potential for the patient to rebreath their own exhaled gases unless the
fresh gas inflow is 2 to 3 times the patient’s minute volume. Figure 84.4 illustrates the most popular form
of breathing circuit, the circle system, with oxygen monitor, circle pressure gage, volume monitor (spirom-
eter), and airway pressure sensor. The circle is a closed system, or semi-closed when the fresh gas inflow
exceeds the patient’s requirements. Excess gas evolves into the scavenging device, and some of the exhaled

FIGURE 84.3 An example of an open circuit breathing system that does not use unidirectional flow valves or
contain a carbon dioxide absorbent.

FIGURE 84.4 A diagram of a closed circuit circle breathing system with unidirectional valves, inspired oxygen
sensor, pressure sensor, and CO2 absorber.

© 2000 by CRC Press LLC

gas is rebreathed after having the CO2 removed. The inspiratory and expiratory valves in the circle system
guarantee that gas flows to the patient from the inspiratory limb and away from the patient through the
exhalation limb. In the event of a failure of either or both of these valves, the patient will rebreath exhaled
gas that contains CO2, which is a potentially dangerous situation.
There are two forms of mechanical ventilation used during anesthesia: (1) volume ventilation, where
the volume of gas delivered to the patient remains constant regardless of the pressure that is required;
and (2) pressure ventilation, where the ventilator provides whatever volume to the patient that is required
to produce some desired pressure in the breathing circuit. Volume ventilation is the most popular since
the volume delivered remains theoretically constant despite changes in lung compliance. Pressure venti-
lation is useful when compliance losses in the breathing circuit are high relative to the volume delivered
to the lungs.
Humidification is an important adjunct to the breathing circuit because it maintains the integrity of
the cilia that line the airways and promote the removal of mucus and particulate matter from the lungs.
Humidification of dry breathing gases can be accomplished by simple passive heat and moisture exchang-
ers inserted into the breathing circuit at the level of the endotracheal tube connectors, or by elegant dual
servo electronic humidifiers that heat a reservoir filled with water and also heat a wire in the gas delivery
tube to prevent rain-out of the water before it reaches the patient. Electronic safety measures must be
included in these active devices due to the potential for burning the patient and the fire hazard.

84.4 Gas Scavenging Systems

The purpose of scavenging exhaled and excess anesthetic agents is to reduce or eliminate the potential
hazard to employees who work in the environment where anesthetics are administered, including oper-
ating rooms, obstetrical areas, special procedures areas, physician’s offices, dentist’s offices, and veteri-
narian’s surgical suites. Typically more gas is administered to the breathing circuit than is required by
the patient, resulting in the necessity to remove excess gas from the circuit. The scavenging system must
be capable of collecting gas from all components of the breathing circuit, including adjustable pressure
level valves, ventilators, and sample withdrawal type gas monitors, without altering characteristics of the
circuit such as pressure or gas flow to the patient. There are two broad types of scavenging systems as
illustrated in Fig. 84.5: the open interface is a simple design that requires a large physical space for the
reservoir volume, and the closed interface with an expandable reservoir bag and which must include
relief valves for handling the cases of no scavenged flow and great excess of scavenged flow.
Trace gas analysis must be performed to guarantee the efficacy of the scavenging system. The National
Institutes of Occupational Safety and Health (NIOSH) recommends that trace levels of nitrous oxide be
maintained at or below 25 parts per million (ppm) time weighted average and that halogenated anesthetic
agents remain below 2 ppm.

84.5 Monitoring the Function of the Anesthesia

Delivery System
The anesthesia machine can produce a single or combination of catastrophic events, any one of which
could be fatal to the patient:
1. delivery of a hypoxic gas mixture to the patient;
2. the inability to adequately ventilate the lungs by not producing positive pressure in the patient’s
lungs, by not delivering an adequate volume of gas to the lungs, or by improper breathing circuit
connections that permit the patient’s lungs to receive only rebreathed gases;
3. the delivery of an overdose of an inhalational anesthetic agent.
The necessary monitoring equipment to guarantee proper function of the anesthesia delivery system
includes at least:

© 2000 by CRC Press LLC

FIGURE 84.5 Examples of open and closed gas scavenger interfaces. The closed interface requires relief valves in
the event of scavenging flow failure.

• Inspired Oxygen Concentration monitor with absolute low level alarm of 19%.
• Airway Pressure Monitor with alarms for:
1. low pressure indicative of inadequate breathing volume and possible leaks
2. sustained elevated pressures that could compromise cardiovascular function
3. high pressures that could cause pulmonary barotrauma
4. subatmospheric pressure that could cause collapse of the lungs
• Exhaled Gas Volume Monitor.
• Carbon Dioxide Monitor (capnography).
• Inspired and Exhaled Concentration of anesthetic agents by any of the following:
1. mass spectrometer
2. Raman spectrometer
3. infrared or other optical spectrometer
A mass spectrometer is a very useful cost-effective device since it alone can provide capnography,
inspired and exhaled concentrations of all anesthetic agents, plus all breathing gases simultaneously (O2 ,
N2 , CO2 , N2O, Ar, He, halothane, enflurane, isoflurane, desflurane, and suprane). The mass spectrometer
is unique in that it may be tuned to monitor an assortment of exhaled gases while the patient is asleep,
including: (1) ketones for detection of diabetic ketoacidosis; (2) ethanol or other marker in the irrigation
solution during transurethral resection of the prostate for early detection of the TURP syndrome, which

© 2000 by CRC Press LLC

results in a severe dilution of blood electrolytes; and (3) pentanes during the evolution of a heart attack,
to mention a few.
Sound monitoring principles require: (1) earliest possible detection of untoward events (before they
result in physiologic derangements); and (2) specificity that results in rapid identification and resolution
of the problem. An extremely useful rule to always consider is “never monitor the anesthesia delivery
system performance through the patient’s physiologic responses”. That is, never intentionally use a device
like a pulse oximeter to detect a breathing circuit disconnection since the warning is very late and there
is no specific information provided that leads to rapid resolution of the problem.

84.6 Monitoring the Patient

The anesthetist’s responsibilities to the patient include: providing relief from pain and preserving all
existing normal cellular function of all organ systems. Currently the latter obligation is fulfilled by
monitoring essential physiologic parameters and correcting any substantial derangements that occur
before they are translated into permanent cellular damage. The inadequacy of current monitoring meth-
ods can be appreciated by realizing that most monitoring modalities only indicate damage after an insult
has occurred, at which point the hope is that it is reversible or that further damage can be prevented.
Standards for basic intraoperative monitoring of patients undergoing anesthesia, that were developed
and adopted by the American Society of Anesthesiologists, became effective in 1990. Standard I concerns
the responsibilities of anesthesia personnel, while Standard II requires that the patient’s oxygenation,
ventilation, circulation, and temperature be evaluated continually during all anesthetics. The following
list indicates the instrumentation typically available during the administration of anesthetics.
Electrocardiogram Non-Invasive or Invasive Blood Pressure
Pulse Oximetry Temperature
Urine Output Nerve Stimulators
Cardiac Output Mixed Venous Oxygen Saturation
Electroencephalogram (EEG) Transesophageal Echo Cardiography (TEE)
Evoked Potentials Coagulation Status
Blood gases and electrolytes (Po2, Pco2, pH, BE, Na+, K+, Cl–, Ca++, and glucose)
Mass Spectrometry, Raman Spectrometry or Infrared Breathing Gas Analysis

Control of Patient Temperature

Anesthesia alters the thresholds for temperature regulation and the patient becomes unable to maintain
normal body temperature. As the patient’s temperature falls even a few degrees toward room temperature,
several physiologic derangements occur: (1) drug action is prolonged; (2) blood coagulation is impaired;
and (3) post-operative infection rate increases. On the positive side, cerebral protection from inadequate
perfusion is enhanced by just a few degrees of cooling. Proper monitoring of core body temperature and
forced hot air warming of the patient is essential.

Monitoring the Depth of Anesthesia

There are two very unpleasant experiences that patients may have while undergoing an inadequate
anesthetic: (1) the patient is paralyzed and unable to communicate their state of discomfort, and they
are feeling the pain of surgery and are aware of their surroundings; (2) the patient may be paralyzed,
unable to communicate, and is aware of their surroundings, but is not feeling any pain. The ability to
monitor the depth of anesthesia would provide a safeguard against these unpleasant experiences. However,
despite numerous instruments and approaches to the problem it remains elusive. Brain stem auditory
evoked responses have come the closest to depth of anesthesia monitoring, but it is difficult to perform,
is expensive, and is not possible to perform during many types of surgery. A promising new technology,

© 2000 by CRC Press LLC

called bi-spectral index (BIS monitoring) is purported to measure the level of patient awareness through
multivariate analysis of a single channel of the EEG.

Anesthesia Computer-Aided Record Keeping

Conceptually, every anesthetist desires an automated anesthesia record keeping system. Anesthesia care
can be improved through the feedback provided by correct record keeping, but today’s systems have an
enormous overhead associated with their use when compared to standard paper record keeping. No
doubt that automated anesthesia record keeping reduces the drudgery of routine recording of vital signs,
but to enter drugs and drips and their dosages, fluids administered, urine output, blood loss, and other
data requires much more time and machine interaction than the current paper system. Despite attempts
to use every input/output device ever produced by the computer industry from keyboards to bar codes
to voice and handwriting recognition, no solution has been found that meets wide acceptance. Tenants
of a successful system must include:
1. The concept of a user transparent system, which is ideally defined as requiring no communication
between the computer and the clinician (far beyond the concept of user friendly), and therefore
that is intuitively obvious to use even to the most casual users.
2. Recognition of the fact that educational institutions have very different requirements from private
practice institutions.
3. Real time hard copy of the record produced at the site of anesthetic administration that permits
real time editing and notation.
4. Ability to interface with a great variety of patient and anesthesia delivery system monitors from
various suppliers.
5. Ability to interface with a large number of hospital information systems.
6. Inexpensive to purchase and maintain.

Alarms
Vigilance is the key to effective risk management, but maintaining a vigilant state is not easy. The practice
of anesthesia has been described as moments of shear terror connected by times of intense boredom.
Alarms can play a significant role in redirecting one’s attention during the boredom to the most important
event regarding patient safety, but only if false alarms can be eliminated, alarms can be prioritized, and
all alarms concerning anesthetic management can be displayed in a single clearly visible location.

Ergonomics
The study of ergonomics attempts to improve performance by optimizing the relationship between people
and their work environment. Ergonomics has been defined as a discipline which investigates and applies
information about human requirements, characteristics, abilities, and limitations to the design, devel-
opment, and testing of equipment, systems, and jobs [Loeb, 1993]. This field of study is only in its infancy
and examples of poor ergonomic design abound in the anesthesia workplace.

Simulation in Anesthesia
Complete patient simulators are hands-on realistic simulators that interface with physiologic monitoring
equipment to simulate patient responses to equipment malfunctions, operator errors, and drug therapies.
There are also crisis management simulators. Complex patient simulators, which are analogous to flight
simulators, are currently being marketed for training anesthesia personnel. The intended use for these
complex simulators is currently being debated in the sense that training people to respond in a prepro-
grammed way to a given event may not be adequate training.

© 2000 by CRC Press LLC

Reliability
The design of an anesthesia delivery system is unlike the design of most other medical devices because
it is a life support system. As such, its core elements deserve all of the considerations of the latest fail-
safe technologies. Too often in today’s quest to apply microprocessor technology to everything, trade-
offs are made among reliability, cost, and engineering elegance. The most widely accepted anesthesia
machine designs continue to be based upon simple ultra-reliable mechanical systems with an absolute
minimum of catastrophic failure modes. The replacement of needle valves and rotameters, for example,
with microprocessor controlled electromechanical valves can only introduce new catastrophic failure
modes. However, the inclusion of microprocessors can enhance the safety of anesthesia delivery if they
are implemented without adding catastrophic failure modes.

Further Information
Blitt, C.D. and Hines R.L., Eds. 1995. Monitoring in Anesthesia and Critical Care Medicine, 3rd ed.
Churchill Livingstone, New York.
Dorsch, J.A. and Dorsch S.E. 1998. Understanding Anesthesia Equipment, 4th ed. Williams and Wilkins,
Baltimore, MD.
Ehrenwerth, J. and Eisenkraft, J.B. 1993. Anesthesia Equipment: Principles and Applications. Mosby, St.
Louis, MO.
Gravenstein N. and Kirby R.R., Eds. 1996. Complications in Anesthesiology, 2nd ed. Lippincott—Raven,
Philadelphia, PA.
Loeb, R. 1993. Ergonomics of the anesthesia workplace. STA Interface 4(3):18.
Miller, R.D. Ed. 1999. Anesthesia, 5th ed. Churchill Livingstone, New York.
Miller, R.D. Ed. 1998. Atlas of Anesthesia. Churchill Livingstone, New York.
Saidman, L.J. and Smith, N.T., Eds. 1993. Monitoring in Anesthesia, 3rd ed. Butterworth-Heinemann,
Stoneham, MA.

© 2000 by CRC Press LLC